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size of 7 mm. A second treatment sitting with the above recurrence. The patient was advised to avoid shaving
settings was repeated after 3 weeks, using the same the posterior part of the hairline close to the skin and
laser applications on each side of the scalp as in the first to avoid wearing clothes that rub or irritate the posterior
treatment. Twelve days after the second sitting, there parts of the scalp and the neck. There was no recurrence
was complete resolution of the lesions with no residual of the lesion seen at 15 months follow‑up.
scarring [Figure 3]. He was kept on observation for any
DISCUSSION

AKN has an unclear etiology, with a predominant
occurrence in males. The probable causes may be
chronic irritation, chronic bacterial infections, or an
autoimmune condition. Treatment of AKN is difficult.
Early cases may be treated with topical potent steroids
or intralesional steroids. Cryotherapy and intralesional
5‑fluorouracil have also been tried. Refractory cases
may respond to laser ablation (e.g., 10.6‑μm carbon
dioxide laser, 1064‑nm Nd:YAG laser, or 810‑nm diode
laser). With long‑pulsed Nd:YAG lasers at a wavelength
of 1064 nm, there is a significant reduction in the
papule count, probably due to the higher penetrance of
the Nd:YAG laser into the dermis to disrupt the follicle,
sparing the epidermis from heat absorption and thereby
Figure 1: Acne keloidalis nuchae of the occipital scalp after failed CO 2 minimizing skin damage. A side effect of the Nd:YAG
[3]
laser treatment and topical steroid and intralesional steroid injection
laser is hair fall‑out, which grows back, but with thinner
hair. The Nd:YAG laser is more suitable for applications
in dark‑skinned individuals (Fitzpatrick IV, V and VI
types). [3]

Diode lasers (using an 810 nm wavelength) act on the
theory of selective thermolysis targeting the melanin
[4]
in the hair follicles. There is coagulation necrosis of
the follicle leading to temporary alopecia. The new
hair that regrows, usually after 4‑6 months, is much
thinner causing less chance of recurrence. Both Nd:YAG
and diode lasers act on the principle of selective
thermolysis, leading to damage in the hair follicle and
thereby causing relief of the disease process. This is in
contrast to the earlier concept of using steroids which
have mainly concentrated on the anti‑inflammatory
response, leading to a decrease in disease activity.
Figure 2: Histological examination showing the skin with orthokeratosis Laser treatment is a relatively painless procedure with
and with increased pigmentation and periadnexal lymphocytic minimal complications. In refractory and advanced cases
inflammatory infiltration
of AKN, both of these laser modalities may have a role
in reducing the number of papules as well as improving
the scar cosmetically.
Our patient presented with a refractory AKN, refractory
to treatment with topical antibiotics, intralesional
steroids, and carbon dioxide laser therapy. We
successfully treated the AKN with both diode and
Nd:YAG lasers. In this case, each laser was equally
effective in ablation of the lesions, with complete
resolution of the symptoms and good cosmetic
outcome. However, the risk of hair loss in the treated
area should be mentioned to the patient. Furthermore,
the chance of the new hair that regrows being much
thinner should be emphasized.
Further, large scale randomized control trials are needed
Figure 3: Post‑Nd:YAG and ‑diode laser therapy; the lesion shows good for assessing the efficacy and advantage of one modality
resolution over the other.
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 41